“No Place Like Home”: Seventh Circuit Confirms ADA Right to Paid Parental Attendant-Care When Needed to Avert Institutionalisation

1. Introduction

Indiana Protection and Advocacy Services Comm’n v. Indiana Family and Social Services Administration (7th Cir., 11 Aug 2025) is a landmark disability-rights decision. At stake were two medically fragile children—E.R. (age 6) and G.S. (age 10)—whose complex conditions require 24/7 supervision. Indiana’s Medicaid waiver historically allowed their mothers, as legally responsible individuals (LRIs), to be reimbursed for “attendant care” (unskilled help with daily living). In July 2024, the State replaced its Aged & Disabled Waiver with a new Health & Wellness Waiver (H&W) that barred LRIs from being paid for attendant care, offering instead the lower-paid “structured family caregiving.” The mothers and Indiana’s P&A agency sued, alleging violations of:

Title II of the Americans with Disabilities Act (ADA) & §504 Rehabilitation Act (the integration mandate);
Several provisions of the Medicaid Act (reasonable-promptness, comparability, EPSDT), though the Seventh Circuit ultimately relied only on the ADA.

The district court issued a preliminary injunction ordering Indiana to keep paying the mothers attendant-care rates until in-home nursing could be arranged. Indiana appealed; the families cross-appealed for broader relief. The Seventh Circuit affirmed.

2. Summary of the Judgment

The court held that removing paid parental attendant care placed the children at a serious risk of institutionalisation, squarely engaging the ADA integration mandate.
Indiana’s budget concerns did not qualify as a “fundamental alteration” defence; the State already provides the same service to other beneficiaries and could continue to do so here.
Recent Supreme Court rulings (Medina, 2025) might limit private enforcement of some Medicaid provisions, but the ADA supplies a secure cause of action, so the preliminary injunction stands independently of Medicaid claims.
The injunction does not force the State to violate federal Medicaid law or to fund care entirely from State dollars; 42 C.F.R. §431.250(b)(2) and CMS guidance allow federal participation for court-ordered payments.

3. Detailed Analysis

3.1 Precedents Cited and Their Influence

Olmstead v. L.C., 527 U.S. 581 (1999) – Recognised unjustified institutional segregation as discrimination; provided the three-part test (professional judgement, no patient objection, reasonable accommodation). The panel applied Olmstead to home-care service design.
Radaszewski v. Maram, 383 F.3d 599 (7th Cir. 2004) – Allowed claims where denial of intensive in-home nursing threatened institutionalisation; used here to reject Indiana’s “new service” argument.
Steimel v. Wernert, 823 F.3d 902 (7th Cir. 2016) – Clarified “serious risk of institutionalisation” standard; quoted extensively for risk analysis and to bar Indiana’s circular reliance on its own waiver language.
Vaughn v. Walthall, 968 F.3d 814 (7th Cir. 2020) – Addressed delegated nursing tasks; distinguished here because Indiana conceded LRIs could lawfully provide attendant care.
Bontrager v. FSSA, 697 F.3d 604 (7th Cir. 2012) – Upheld injunction against Medicaid service cap; used to evaluate equitable balancing.
Armstrong v. Exceptional Child Center, 575 U.S. 320 (2015) – Barred private §1983 suits to enforce Medicaid rate-setting clause; Indiana claimed this blocked relief, but the panel held Armstrong irrelevant where plaintiffs seek who may be paid, not how much.
Medina v. Planned Parenthood South Atlantic, 145 S.Ct. 2219 (2025) – Cast doubt on Medicaid private-action doctrine; the panel cautiously deferred Medicaid questions but emphasised ADA sufficiency.

3.2 Court’s Legal Reasoning

Likelihood of Success – Plaintiffs satisfied Olmstead’s first two prongs (professional support and family willingness). Indiana failed its “fundamental alteration” defence: allowing paid parental care is merely a modification of provider type, not a new service, and does not demonstrably increase costs over institutional care.
Irreparable Harm – Without paid attendant care, mothers must work outside the home, leaving no qualified caregiver; institutional placement is certain, not speculative.
Balance of Equities / Public Interest – Protecting medically necessary, integrated home care outweighs unsubstantiated fiscal fears. Medicaid’s purpose is to serve the most vulnerable.
Scope & Funding – 42 C.F.R. §440.167 forbids federal match for ordinary parental duties, but CMS will match “extraordinary” care – exactly what these children require. Section 431.250(b)(2) further allows federal match when a court compels payment.
Armstrong Misapplied – Because the families did not seek higher rates but a different eligible provider, their ADA claim is not a “ratemaking” challenge.

3.3 Potential Impact

National Guidance on LRIs – States that uncritically ban LRI payment in waiver redesigns now risk ADA litigation if such bans place beneficiaries at risk of institutionalisation.
Fiscal-First Waiver Reforms Curtailed – Budgetary shortfalls alone cannot justify cutting integrated-care options without rigorous evidence; cheapness is not a defence to discrimination.
Medicaid Litigation After Medina – The opinion demonstrates that even if Medicaid §1983 avenues narrow, plaintiffs can pivot to ADA/Rehab Act theories to secure access to community-based care.
Strategic Use of Preliminary Injunctions – The Seventh Circuit again endorses interim equitable relief in disability cases to avoid forced institutional placements while merits proceed.
Administrative Practice – Encourages states to craft “provider-of-last-resort” LRI policies rather than categorical prohibitions. CMS technical guidance may be revisited to clarify federal-match rules.

4. Complex Concepts Simplified

ADA Integration Mandate – Requires government services be delivered in community settings when safe and appropriate; segregation is discriminatory.
Legally Responsible Individual (LRI) – A parent (for minors) or spouse legally obliged to provide basic care; Medicaid usually bars paying LRIs for ordinary tasks but allows payment for extraordinary care.
Medicaid Waiver – State-specific program that “waives” certain federal rules so states can fund community services instead of institutions, subject to CMS approval.
Attendant Care vs. Structured Family Caregiving – Both are non-skilled help with daily living; attendant care is hourly & higher-paid, SFC is per-diem & lower-paid.
Fundamental Alteration Defence – State may refuse accommodations that would radically change a program’s nature or cost; heavy burden on the State.
Preliminary Injunction – Emergency court order preserving the status quo during litigation if the plaintiff shows likely success, irreparable harm, and equities favour urgent relief.
Federal Financial Participation (FFP) – The federal share of Medicaid payments; states fear losing FFP if they fund services outside approved plans.

5. Conclusion

Indiana P&A v. FSSA is now a leading authority that States cannot use cost-saving Medicaid waiver revisions to sever the only safe caregiving arrangement keeping medically fragile children at home. The Seventh Circuit re-affirmed that:

Serious risk of institutionalisation, not actual placement, triggers ADA protection.
Budget constraints rarely satisfy the “fundamental alteration” defence, especially when home care costs less than institutionalisation.
Armstrong’s limits on Medicaid rate litigation do not bar ADA suits focused on discriminatory provider restrictions.
Court-ordered payments to parental caregivers can remain within Medicaid’s federal-funding framework.

Going forward, states redesigning waiver programs must build flexible, evidence-based provisions for LRI caregivers or face swift ADA challenges. For advocates, Olmstead remains a powerful tool, independent of the evolving §1983 landscape after Medina. Above all, the decision reinforces a simple principle: when safe, loving home care is feasible, disability law demands that bureaucratic rules bend before vulnerable lives break.